Instructions for Obtaining

Prescription Safety Glassesat the National Institutes of Health, Bethesda, Maryland

Initial (NEW) Request According to the Occupational Health and Safety Administration’s 29 CFR 1910.133, all NIH employees who are engaged in eye- hazardous occupations shall wear safety glasses that conform with American National Standards Institute’s Z87 Standard for Occupational and Educational Personal Eye and Face Protection Device.

The purchase of non-prescription safety glasses or goggles for the employee is the responsibility of the Institute or Center and does not require the attached form.

Prescription safety glasses will be furnished by the Occupational Medical Services (OMS), Division of Occupational Health and Safety. The employee must provide the prescription if required. NIH will pay for the glasses furnished by the contract optician up to $45.00. The employee must pay any charges over this amount. The NIH will also pay charges for measuring, fitting, and subsequent lens replacement or repair performed by the contract optician. If an employee who has been issued safety glasses is separated from NIH, he may keep the glasses and case without charge.

Prescription The prescription must be written by an opthalmologist or optometrist. No

prescription over one year old will be accepted. Your work requirements might require safety glasses that differ from off- the-job glasses. Please discuss your needs with the prescription writer so that adequate glasses may be specified. Clear lenses made of polycarbonate are normally supplied. Other plastic lenses scratch easily and will be furnished only for prescriptions having a total sphere and cylinder power above 4.00 D where glass lenses would pose a weight problem. Plastic, tinted, coated, photochromic lenses, clip-on sun shades, or didymium lenses will not be furnished unless specifically authorized by the Contract Project Officer.

Prepare the attached request form. Fill in Section A, and check “New” box. Have your supervisor (Section Chief or equal) sign the certification statement, Section B and attach the prescription to the request form.

Hand-carry the request form to the OMS Health Unit, Building 10, RM 6C310, for approval of safety glasses. The Optician will provide measurement and selection options on the 2nd and 4th Tuesday from 8 am- 10 am. You will be notified via e-mail or telephone for all appointments and pick-up of glasses.

Repair or Replace

The request form may be used for obtaining repair or replacement of safety glasses which have been issued by NIH. Costs for repairs or replacement will be paid for by NIH. The employee must pay for the prescription if the repair or replacement involves prescription glasses.

Repair Complete Section A, checking the “Repair” box. Under “Comments,” describe the damage. If the repair involves replacement of one or both lenses, a new prescription will be required if the prescription used to obtain the glasses is over one year old at the time of the request for repair.

The original frames, if still serviceable, will be used in a replacement due to a prescription change. Fill in forms as in initial request, but check “Replacement” box.

If glasses are lost and a replacement pair is desired, check “Replacement” box, write “Lost” under “Comments,” and attach a brief statement describing the circumstances of the loss. If the prescription used for obtaining the lost glasses is over one year old, a new prescription will be required.

Replace

NIH 29-2 (09/12) Instructions, Page 1

Prescription Safety Glasses Policy

Employees shall wear safety glasses whenever a reasonable probability exists of eye injury resulting from the work being performed. Staff shall use appropriate eye or face protection when exposed to hazards from biological materials, flying particles, liquid chemicals, acids or caustics, chemical gases or vapors, or potentially injurious light radiation, per 29 CFR 1910.133, Eye and Face Protection, Occupational Safety and Health regulations. Safety Specialists in the Division of Occupational Health and Safety are available to assist with hazard assessments and selection of appropriate personal protective equipment.

Prescription ground safety glasses will be provided, where required.

It is the responsibility of the employee to notify his/her immediate supervisor/ manager of the need for prescription safety glasses when eye protection is required by the nature of the duties of his/her position. Employees are required to ensure that prescription safety glasses are properly fitted, used, maintained, and stored.

The supervisor/manager will ensure that when needed, employees requiring the use of prescription safety glasses will obtain and use the necessary personal protective equipment consistent with the requirements of their duties.

Privacy Act Statement

The Division of Occupational Health and Safety, Office of Research Services, NIH, collects the information on this form in order to provide safety glasses to employees engaged in eye-hazardous occupations. Submission of the form is voluntary; however, the Division of Occupational Health and Safety will not provide safety glasses without it.

The information on this form is maintained under the authority of 5 U.S.C. 5901, 7902-3, and Section 509 of the Public Health Service Act (42 U.S.C. 227).

It is part of Privacy Act system of records number 09-25-0007. Except as specifically permitted by the Privacy Act, personal information on this form will not be disclosed outside this agency except (1) to a congressional office at your request or (2) to the Department of Justice if it is necessary to use the information in defending you, this agency, or the Government in a law suit.

NIH 29-2 (09/12) Instructions, Page 2

Request for Prescription Safety GlassesNational Institutes of HealthSection A – Employee Information (To be completed by Employee)

Atta

ch P

resc

riptio

n H

ere

Name of Employee

Position

IC Laboratory or Branch

Building Room Telephone

Type of EmployeeCivil ServiceCommissioned Corps

Other (specify)

Prescription Date Date of Request

Type of Occupation (Check one)

Laboratory

ORF:

Clinical Center

Special

Other (Describe hazards)

Type of Order (Check one)

New Replace Repair

Comments

Section B – Certification (To be completed by Section Chief or equal)

This NIH employee is engaged in an occupation that presents a reasonable probability of eye injury resulting from the work being performed.Signature of Supervisor Date

Section C – Approval (To be completed by Occupational Medical Service [OMS] at Health Unit)Signature of OMS Representative Date

Section D – Contract Information (To be completed by Optician)

Note to Optician:Please discuss with the employee his/her work requirements so that adequate safety glasses may be provided. No prescription over one year old will be accepted. Glass lenses will be used except where glass lenses would pose a weight problem. Plastic

lenses will be furnished only for prescriptions having a total sphere and cylinder power above 4.00 D. See NOTE on right side of this section for items which require specific authorization. Have the employee sign at the bottom of this section when glasses are delivered.

Contract Room Number

Frame:

Case:

Lenses:

Measured by Date

Fitted by Date

NOTE: These items will be furnished only if authorized by the Contract Project Officer.

Plastic lenses

Tinted lenses

Coated lenses

Photocromic lenses

Clip-on sun shades

Didymium lenses

Signature of Employee (when glasses are received) Signature of OMS Representative

NIH 29-2 (09/12)